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July 2017

Dart Container of Michigan’s employee groups to join Medical Drug Prior Authorization Program

Beginning Sept. 1, 2017, Dart Container of Michigan’s active and retired employee groups will participate in the Medical Drug Prior Authorization Program.

The following list shows all medications currently in the Medical Drug Prior Authorization Program.

Drug name

Actemra

Elaprase®

Kanuma™

Ruconest®

Acthar® gel

Elelyso™

Krystexxa®

Signifor® LAR

Adagen®

Entyvio™

Lemtrada™

Simponi Aria®

Aldurazyme®

Exondys 51™

Lumizyme®

Soliris®

Aralast NP™

Fabrazyme®

Makena®

Spinraza™

Aveed®

Firazyr®

Myobloc®

Stelara®

Benlysta®

Flebogamma® DIF

Myozyme®

Stelara IV®

Berinert®

Gammagard Liquid®

Naglazyme®

Synagis®

Bivigam™

Gammagard® S/D

Nplate®

Testopel®

Botox®

Gammaked®

Nucala®

Tysabri®

Brineura™

Gammaplex®

Ocrevus™

Vimizim™

Carimune® NF

Gamunex®

Octagam®

Vpriv®

Cerezyme®

Glassia™

Orencia®

Xeomin®

Cimzia®

Hizentra®

Privigen®

Xgeva®

Cinqair®

HyQvia®

Probuphine®

Xiaflex®

Cinryze®

Ilaris®

Prolastin®-C

Xolair®

Cosentyx™

Immune globulin

Prolia®

Zemaira®

Cuvitru®

Inflectra™

Radicava™

Zinplava™

Dysport®

Kalbitor®

Remicade®

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.
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